The American Indian/Alaska Native National Resource Center
for Substance Abuse and Mental Health Services
Providing Behavioral Health Care in Native
Communities: Social Determinants
of Health
Oregon Health and Science University
Portland, Oregon March 2, 2010
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer
Global Health Lecture Series
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One Sky
Center
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One Sky Center Partners
Cook Inlet Tribal Council
Alaska Native Tribal
Health Consortium
Northwest Portland Area
Indian Health Board
Tribal Colleges
and Universities
Prairielands ATTC
Red Road
One Sky
Center
United American
Indian Involvement
Harvard Native
Health Program
Jack Brown
Adolescent
Treatment Center
National Indian Youth
Leadership Project
Tri-Ethnic Center for
Na'nizhoozhi Center Prevention Research
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One Sky Center Outreach
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Goals for Today
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Define Social Determinants of Health
Review An Environmental Scan for Natives
Discuss Fragmentation and Integration
Present Some Behavioral Health Care Issues
Present Examples of Treatment and Prevention
Summarize Critical Issues for Native Peoples
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The Social Determinants of Health
• The conditions in which people are born, grow,
live, work and age.
• Shaped by the distribution of money, power and
resources at global, national and local levels.
• Are mostly responsible for health inequities the unfair and avoidable differences in health
status seen within and between countries.
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Social Determinants of Health
• Ubiquitous
• Powerful influence on health
• Underlie:
– Differences between individuals within countries
– Differences between groups, populations and
countries
– Changes in health over time
• Complex pathways
WHO Social Determinant Themes
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Social exclusion
Urbanization
Globalization
Health systems
Priority public health conditions
Early child development
Women and gender equity
Employment conditions
Measurement and evidence
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WHO ARE INDIGENOUS
PEOPLES?
“Indigenous peoples remain on the margins
of society: they are poorer, less educated, die
at a younger age, are much more likely to
commit suicide, and are generally in worse
health than the rest of the population."
(Source: The Indigenous World 2006, International Working
Group on Indigenous Affairs (IWGIA) WHO
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INDIGENOUS PEOPLE
WORLD MAP - 370 million indigenous
peoples living in more than 70 countries
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Native Health Issues
1.
2.
3.
4.
5.
6.
7.
8.
Alcoholism 6X
Tuberculosis 6X
Diabetes 3.5 X
Accidents 3X
Poverty 3x
Depression 3x
Suicide 2x
Violence?
1. Same disorders as
general population
2. Greater prevalence
3. Greater severity
4. Much less access
to Tx
5. Cultural relevance
more challenging
6. Social context
disintegrated
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Native Healthcare Resource
Disparities
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Agencies Involved in B.H. Delivery
1. Indian Health Service (IHS)
A. Mental Health
B. Primary Health
C. Alcoholism / Substance Abuse
2. Bureau of Indian Affairs (BIA)
A. Education
B. Vocational
C. Social Services
D. Police
3. Tribal Health
4. Urban Indian Health
5. State and Local Agencies
6. Federal Agencies: SAMHSA, VAMC,
Justice
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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning?
(Carl Bell and Dale Walker 7/03)
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Culturally
Specific
Best
Practice
Outcome
Driven
Integrating
Resources
We need Synergy and an Integrated System
(Carl Bell and Dale Walker 7/03)
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Behavioral Health Care Issues
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Adult Serious Mental Illness
By Race/Ethnicity: 2001
SAMHSA Office of Applied Studies, 2001
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Frequent Mental Distress
by Race/Ethnicity and Year
Percent
American Indian/
Alaskan Native**
African-American**
Hispanic
White**
Asian, Pacific Islander**
** Non-Hispanic
Year
* Zahran HS, et al. Self-Reported Frequent Mental Distress Among Adults —
United States, 1993–2001. Centers for Disease Prevention and Control, 22
MMWR 2004;53(41):963-966.
Mental Illness: A Multi-factorial Event
Psychiatric Illness
& Stigma
Edu., Econ., Rec.
Cultural Distress
Impulsiveness
Substance
Use/Abuse
Family Disruption/
Domestic Violence
Individual
Negative Boarding School
Historical Trauma
Hopelessness
Family History
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
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Key Adolescent Risk Factors
Aggressive/Impulsive
Substance Abuse
Depression
Trauma
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Six behaviors that contribute to
serious health problems:
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Tobacco use
Poor nutrition
Alcohol and other drug abuse
Behaviors resulting in intentional or unintentional
injury
• Physical inactivity
• Risky sex
http://www.cdc.gov/HealthyYouth/healthtopics/index.htm
Suicide Among ages 15-17, 2001
Death rate per 100,000
16
14
12
10
8
6
4
2010
Target
2
00
Total
Females Males
Source: National Vital Statistics System - Mortality, NCHS, CDC.
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Suicide: A Native Crisis
AI Male
Black Male
AI Female
50
40
30
20
Age Groups
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Source: National Center for Health Statistics 2001
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
0
10-14
10
5-9
Rate/100,000 .
60
White Male
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North Dakota Teen Suicide Rates
(2000-2004 rate per 100,000 teens 13-19 years old)
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Disaster Defined
• FEMA: A natural or man-made event that negatively
affects life, property, livelihood or industry often
resulting in permanent changes to human societies,
ecosystems and environment.
• NHTSA: Any occurrence that causes damage,
ecological destruction, loss of human lives, or
deterioration of health and health services on a scale
sufficient to warrant an extraordinary response from
outside the affected community area.
• NOAA: A crisis event that surpasses the ability of an
individual, community, or society to control or recover
from its consequences.
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Models of Care
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Domains Influencing Behavioral Health:
A Native Ecological Model
Risk
Individual
Protection
Peers/Family Community/Tribe
Society/Cultural
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Spectrum of Intervention Responses
Thresholds for Action
No
Problems
Mild
Problems
Moderate
Problems
Severe
Problems
Treatment
Brief Intervention
Universal/Selective
Prevention
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The Intervention Spectrum for
Behavioral Disorders
Case
Identification Standard
Treatment
for Known
Indicated—
Disorders
Diagnosed
Youth
Selective—
Health Risk
Groups
Universal—
General Population
Compliance
with Long-Term
Treatment
(Goal:Reduction in
Relapse and Recurrence)
Aftercare
(Including
Rehabilitation)
Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine,
Washington, DC: National Academy Press, 1994.
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Risk and Protective Factors:
Individual
Risk
Mental illness
Age/gender
Substance abuse
Loss
Previous suicide attempt
Personality traits
Incarceration
Failure/academic problems

Protective
Cultural/religious beliefs
Coping/problem solving skills
Ongoing health and mental health
care
Resiliency, self esteem, direction,
mission, determination,
perseverance, optimism, empathy
Intellectual competence, reasons
for living

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Individual Intervention
• Identify risk and protective factors
counseling
skill building
improve coping
support groups
• Increase community awareness
• Access to hotlines other help resources
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Effective Interventions for Adults
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Cognitive/Behavioral Approaches
Motivational Interventions
Psychopharmacological Interventions
Modified Therapeutic Communities
Assertive Community Treatment
Vocational Services
Dual Recovery/Self-Help Programs
Consumer Involvement
Therapeutic Relationships
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Culture-Based Interventions
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Story telling
Sweat Lodge
Talking circle
Vision quest
Wiping of tears
Drumming
Smudging
Traditional Healers
Herbal remedies
Traditional activities
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Definition:
Indigenous
Knowledge
• Local knowledge unique to a given culture or
society; it has its own theory, philosophy,
scientific and logical validity, used as a basis
for decision-making for all of life’s needs.
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Definitions:
Traditional Medicine
• The sum total of health knowledge,
skills and practices based upon
theories, beliefs and experiences
indigenous to different cultures…used in
the maintenance of health.
WHO 2002
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ID Best Practice
Best Practice
Clinical/services
Research
Mainstream
Practice
Traditional
Medicine
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What are some promising strategies?
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An Ideal Intervention
• Broadly based:
Includes individual, family,
community, tribe, and society
• Comprehensive:
Prevention: Universal, Selective,
Indicated
Treatment
Maintenance
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Choctaw Nation of Oklahoma
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Adventure Therapy
“Natural Highs Program”
Transformation process
Experiential activities
Relationship building
Changing the way you live and think
Changing how you think and how
you believe about life and yourself
Creation of challenge in a safe
environment
Horses, Canoes, Tradition Camps
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Meth Free Crow Walk: Youth as
our Warriors in Reclaiming our
Nation
Meth Free Crowalition
• Establish a “War Against
Meth” Focus on
accountability, prevention,
intervention, and
treatment
• Combine forces for Unity.
• Diverse community
representation
• Youth and Community
Development: mentorship,
leadership, trust, establish
community norms
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Integrated Treatment
Premise: treatment at a single site, featuring
coordination of treatment philosophy,
services and timing of intervention will be
more effective than a mix of discrete and
loosely coordinated services
Findings:
• decrease in hospitalization
• lessening of psychiatric and substance abuse
severity
• better engagement and retention
(Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)
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Comprehensive School Planning
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Prevention and behavioral health programs/services on site
Handling behavioral health crises
Responding appropriately and effectively after an event
Public awareness and media campaigns
Youth Development Services
Social Interaction Skills Training Approaches
Mentoring
Tutoring
Rites of Passage
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Partnered Collaboration
State/Federal
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
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Six Key Principles
Evidence-based predictors of change
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Leadership
Mobilization Community driven
Public health approach
Strength based
Culturally informed
Proactive
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Critical Elements for Native Peoples
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Self determination
Ecology and environment
Economic prosperity, fairness and equity
Leadership and capacity strengthening
Racism / dominance / imperialism
Healing, services, systems, structures
Cultural sustainability, protection, stewardship
Land
Human rights
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Areas for Action
Health Equity in all Policies
Good Global
Governance
Fair Financing
Market
Responsibility
Early child development and
education
Healthy Places
Fair Employment
Social Protection
Universal Health Care
Gender Equity
Political empowerment
– inclusion and voice
NIDA American Indian
Research Scholars
Mentorship Program
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Location of Mentors =
and Mentees = in Project
X
X
X
X
X
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X
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Contact us at
503-494-3703
E-mail
Dale Walker, MD
onesky@ohsu.edu
Or visit our website:
www.oneskycenter.org
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